Firefighter Dies after Falling through a Roof Following Ventilation-the NIOSH Report

On September 14, 2002, a 53-year-old male career firefighter died after falling through a roof following roof ventilation operations at a house fire. The victim, who was not wearing a self-contained breathing apparatus (SCBA), was observing another fire fighter who was wearing an SCBA while making ventilation cuts. After making the last cut, the victim, who had been covering his face with his hands, told his partner that they had to leave immediately. The firefighters retreated toward the aerial platform, but the victim stopped a few feet from the platform, saying he could not continue. Seconds later, the area of the roof under the victim failed, and he fell through the roof into the structure and the fire. Within minutes the interior attack crew found the victim and, with the help of the Rapid Intervention Team (RIT), removed him. He was transported to a local hospital where he was pronounced dead.

On September 17, 2002, the U.S. Fire Administration (USFA) notified the National Institute for Occupational Safety and Health (NIOSH) of this incident. On October 16-17, 2002, three safety and occupational health specialists from the NIOSH Fire Fighter Fatality Investigation and Prevention Program investigated the incident. NIOSH investigators met with the Chief of the department, the International Association of Fire Fighters (IAFF) representative, and the State Fire Marshal. The NIOSH team interviewed the Chief and the firefighters directly involved in the incident. NIOSH investigators took photographs of the incident site and reviewed the department standard operating procedures (SOPs), pictures of the incident taken by the fire department, training records of the victim, reports of the State Fire Marshal concerning the incident, and the autopsy report.

This career department has 38 uniformed personnel in two fire stations and serves a population of approximately 23,000 in an area of about 15 square miles. It respond to 15-20 structure fires per year. The department requires that new recruits complete NFPA Fire Fighter Level I training before completing probation. The victim had 27 years of experience as a career fire fighter and during this time had taken numerous training courses including Ventilation, Fire Tactics, and Live-Fires. He was certified as an NFPA Fire Fighter Level I and II. The victim had performed vertical ventilation on many structure fires prior to this incident.

The structure was a 96-year-old, 2 1/2-story wood-frame dwelling with balloon-frame construction. The roof was steeply pitched and had intersecting gables consisting of 2- by 4-inch timbers covered with 1-inch wood planks and 4-5 layers of asphalt shingles. The building was located on a corner lot on a grade. The second floor was accessed at street level from the rear. The top floor was used for storage and was accessed via an internal stairway. No one was home at the time of the incident.

According to the State Fire Marshal’s Office and the Fire Department, the origin and cause of the fire was faulty electrical wiring in a ceiling fan between the ceiling of a second-story room and the top floor.

The cause of death per the autopsy report was smoke inhalation, intra-alveolar hemorrhage, and carbon monoxide intoxication (carboxyhemoglobin level, 30.3%).

NIOSH investigators concluded that, to minimize the risk of similar incidents, fire departments should:

  • Enforce existing standard operating procedures (SOPs) for structural fire fighting, including the use of self-contained breathing apparatus (SCBA), Incident Command System, Truck Company Operations, and Transfer of Command;
  • Ensure that the Incident Commander evaluates resource requirements during the initial size-up and continuously evaluates the risk versus benefit when determining whether the operation will be offensive or defensive;
  • Develop, implement and enforce SOPs regarding vertical ventilation procedures;
  • Review dispatch/alarm response procedures with appropriate personnel to ensure that the processing of alarms is completed in a timely manner and that all appropriate units respond according to existing SOPs;
  • Ensure that Incident Command maintains the role of director of fireground operations and does not become involved in firefighting efforts;
  • Ensure that adequate numbers of staff are available to immediately respond to emergency incidents;
  • Consider using a thermal imaging camera (TIC) as part of the exterior size-up.

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